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  ความจริงเกี่ยวกับเรื่อง 
  Multiple Sclerosis (MS)  

What is MS?
  โรค Multiple sclerosis MS

What causes MS?
  สาเหตุของการเกิดโรค

What are the symptoms 
   of MS?
  ลักษณะอาการของโรค

Who gets MS?
  ใครที่สามารถมีอาการนี้ได้บ้าง

What are the types of
   MS?
   กลุ่มชนิดของอาการ

Which Drug?
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   ความจริงเกี่ยวกับเรื่อง Multiple Sclerosis (MS)        

ความจริงเกี่ยวกับเรื่อง Multiple Sclerosis (MS)  มัลติเปิ้ล สเคอโรซิส

MS is one of the most common diseases of the central nervous system in young adults

Sclerosis means scars these are the plaques or lesions in the brain and spinal cord

In MS, the protective myelin covering of the nerve fibres in the central nervous system is damaged

Inflammation and ultimate loss of myelin causes disruption to nerve transmission and affects many functions of the body

While the exact cause of MS is not known, much is known about its effect on immune system function which may be the ultimate cause of the disease

MS is not directly hereditary, although genetic susceptibility plays a part in its development

MS is not contagious

More women than men have MS

Diagnosis of MS is generally between 20 and 40 years of age, although onset may be earlier

MS is rarely diagnosed under 12 and over 55 years of age

Life span is not significantly affected by MS

Fatigue is a common symptom of MS

MS is more common in countries further from the equator

Heat can cause symptoms to worsen temporarily in many people with MS

There is no drug that can cure MS, but treatments are now available which can modify the course of the disease

Your doctor and your national MS society are important sources of information about MS

Many of the symptoms of MS can be successfully managed and treated

What is MS?

Multiple Sclerosis is one of the most common diseases of the central nervous system (brain and spinal cord). MS is an inflammatory demyelinating condition. Myelin is a fatty material that insulates nerves, acting much like the covering of an electric wire and allowing the nerve to transmit its impulses rapidly. It is the speed and efficiency with which these impulses are conducted that permits smooth, rapid and co-ordinated movements to be performed with little conscious effort. In Multiple Sclerosis, the loss of myelin (demyelination) is accompanied by a disruption in the ability of the nerves to conduct electrical impulses to and from the brain and this produces the various symptoms of MS. The sites where myelin is lost (plaques or lesions) appear as hardened (scar) areas: in Multiple Sclerosis these scars appear at different times and in different areas of the brain and spinal cord - the term Multiple Sclerosis meaning, literally, many scars.

What causes MS?
The cause of Multiple Sclerosis is not yet known, but thousands of researchers all over the world are meticulously putting the pieces of this complicated puzzle together. The damage to myelin in MS may be due to an abnormal response of the body's immune system, which normally defends the body against invading organisms (bacteria and viruses). Many of the characteristics of MS suggest an 'auto-immune' disease whereby the body attacks its own cells and tissues, which in the case of MS is myelin. Researchers do not know what triggers the immune system to attack myelin, but it is thought to be a combination of several factors. One theory is that a virus, possibly lying dormant in the body, may play a major role in the development of the disease and may disturb the immune system or indirectly instigate the auto-immune process. A great deal of research has taken place in trying to identify an MS virus. It is probable that there is no one MS virus, but that a common virus, such as measles or herpes, may act as a trigger for MS. This trigger activates white blood cells (lymphocytes) in the blood stream, which enter the brain by making vulnerable the brain's defence mechanisms ( i.e. the blood/brain barrier). Once inside the brain these cells activate other elements of the immune system in such a way that they attack and destroy myelin. 

What are the symptoms of MS?
Multiple Sclerosis is a very variable condition and the symptoms depend on which areas of the central nervous system have been affected. There is no set pattern to MS and everyone with MS has a different set of symptoms, which vary from time to time and can change in severity and duration, even in the same person. The systems commonly affected include:

  • vision
  • co-ordination
  • strength
  • sensation
  • speech and swallowing
  • bladder control
  • sexuality
  • cognitive function

There is no typical MS. Most people with MS will experience more than one symptom, and though there are symptoms common to many people, no person would have all of them.

Visual disturbances:
  • blurring of vision
  • double vision (diplopia)
  • optic neuritis
  • involuntary rapid eye movement (rarely) total loss of sight

Balance & co-ordination problems:

  • loss of balance
  • tremor
  • unstable walking (ataxia)
  • giddiness (vertigo)
  • clumsiness of a limb
  • lack of co-ordination

Weakness:

  • this can particularly affect the legs and walking

Spasticity:

  • altered muscle tone can produce spasticity or muscle stiffness which can affect mobility and walking
  • spasms

Altered sensation:

  • tingling, numbness (paraesthesia), or burning feeling in an area of the body
  • other indefinable sensations

Pain may be associated with MS, e.g. facial pain, (such as trigeminal neuralgia), and muscle pain

Abnormal speech:

  • slowing of speech
  • slurring of words
  • changes in rhythm of speech
  • Difficulty in swallowing (dysphagia)

Fatigue:

  • a debilitating kind of general fatigue which is unpredictable or out of proportion to the activity. Fatigue is one of the most common (and one of the most troubling) symptoms of MS

Bladder & bowel problems:

  • bladder problems include the need to pass water frequently and/or urgently, incomplete emptying or emptying at inappropriate times.
  • bowel problems include constipation and, infrequently, loss of bowel control

Sexuality & intimacy:

  • impotence
  • diminished arousal
  • loss of sensation

For more information see 'Relationships, Intimacy & Sexuality' section of WoMS

Sensitivity to heat:

  • this symptom very commonly causes a transient worsening of symptoms

Cognitive & emotional disturbances:

  • problems with short term memory, concentration, judgment or reasoning

For more information see MS by Topic - 'Cognitive Problems'

Whilst some of these symptoms are immediately obvious, others such as fatigue, altered sensation, memory and concentration problems are often hidden symptoms. These can be difficult to describe to others and sometimes family and carers do not appreciate the effects these have on the person with MS and on employment, social activities and quality of life.


Who gets MS?

Women are more likely to develop Multiple Sclerosis than men, MS occurring 50% more frequently in women than in men (i.e. 3 women for every 2 men). Multiple Sclerosis is a disease of young adults, the mean age of onset is 29-33 years, but the range of onset is extremely broad from approximately 10-59 years. With the advent of specialized diagnostic markers such as the Magnetic Resonance Imaging scanner (MRI) there are cases of MS being definitely diagnosed in childhood rather than in adolescence and the 15 years lower age limit which is traditionally quoted in many texts and handouts should not be taken as a fixed boundary for onset of the disease. MS is not contagious, your friends and family cannot catch it from you. MS is not an inherited disease, nor is it genetically transmitted, but there does appear to be some genetic susceptibility to the disease, which explains the fact that there is a slightly higher risk of Multiple Sclerosis in families where it has already occurred. The slightly increased risk to children and siblings of those with MS may reflect a common susceptibility and a similar environment. It is important to establish who is most likely to develop MS and the geographic areas of highest incidence. In the world map of MS prevalence, MS appears to be a disease of temperate rather than tropical climates (i.e. there is more MS the further one lives from the equator). In Northern Europe, particularly Scandinavia and Scotland, there is a high incidence of MS, which may reflect a specific susceptibility of the native population. Migration at particular ages can affect susceptibility to developing MS. A child migrating from an equatorial to temperate area (or temperate to equatorial) before puberty acquires the risk of the area to which he/she has moved. The same relocation by an adolescent (or older person) retains the risk characteristic of the area from which he/she moved. 


What are the types of MS?
The course of MS is unpredictable. Some people are minimally affected by the disease while others have rapid progress to total disability, with most people fitting between these two extremes. Although every individual will experience a different combination of MS symptoms there are a number of distinct patterns relating to the course of the disease: 

Relapsing-Remitting MS: 
In this form of MS there are unpredictable relapses (exacerbations, attacks) during which new symptoms appear or existing symptoms become more severe. This can last for varying periods (days or months) and there is partial or total remission (recovery). The disease may be inactive for months or years. 
Frequency - approx 25% 

Benign MS: 
After one or two attacks with complete recovery, this form of MS does not worsen with time and there is no permanent disability. Benign MS can only be identified when there is minimal disability 10-15 years after onset and initially would have been categorised as relapsing-remitting MS. Benign MS tends to be associated with less severe symptoms at onset (e.g. sensory). 
Frequency - approx 20% 

Secondary Progressive MS: 
For some individuals who initially have relapsing-remitting MS, there is the development of progressive disability later in the course of the disease often with superimposed relapses. 
Frequency - approx 40% 

Primary Progressive MS: 
This form of MS is characterised by a lack of distinct attacks, but with slow onset and steadily worsening symptoms. There is an accumulation of deficits and disability which may level off at some point or continue over months and years. 
Frequency - approx 15% 


Diagnosing MS
Early MS may present itself as a history of vague symptoms which may have subsided and many of the signs could be attributed to a number of medical conditions. Therefore, a period of time may elapse and a prolonged diagnostic process may be involved before MS is suggested. On the other hand, a possible diagnosis of MS may be more clearcut with classic symptoms (e.g. optic neuritis) and a distinct chronology of attacks. The neurologist requires evidence that the types of neurological deficits indicate involvement of at least two different areas of the central nervous system with effects occurring at two separate times.

Multiple Sclerosis is essentially a clinical diagnosis and there are no tests which are specific for the condition and no single test is 100% conclusive. Therefore several tests and procedures are needed to establish a diagnosis of MS and they include the following investigations:

Medical History
  • The physician will ask for a medical history which will include your past record of signs and symptoms as well as the current status of your health. The type of symptoms, their onset and pattern may suggest MS, but a full physical examination and medical tests will be needed to confirm the diagnosis.
Neurological Examination
  • The neurologist is testing for abnormalities in nerve pathways. Some of the more common neurologic signs involve changes in eye movements, limb co-ordination, weakness, balance, sensation, speech, and reflexes. However, this examination cannot conclude what is causing the abnormality and so other possible causes of illness which produce similar symptoms to MS must be eliminated.
Testing of Visual and Auditory Evoked Potentials
  • When demyelination (scarring) occurs the conduction of messages along the nerves may be slowed. Evoked potentials measure the time taken for the brain to receive and intepret messages (nerve conduction velocity). This is done by placing small electrodes on the head which monitor brain waves in response to visual and auditory (hearing) stimuli. Normally, the brain's reaction to such stimuli is almost instantaneous, but if there is demyelination in the central nervous system a delay may occur. This test is not invasive or painful and therefore does not require a stay in hospital.
Magnetic Resonance Imaging (MRI)
  • The MRI scanner is a more recent diagnostic test and takes very detailed pictures of the brain and spinal cord, showing any existing areas of sclerosis (lesions or plaques). Whilst this is the only test in which the lesions of Multiple Sclerosis can be seen, it cannot be regarded as conclusive, particularly as not all lesions may be picked up by the scanner and because many other conditions can produce identical abnormalities. The MRI clearly shows the size, quantity and distribution of lesions, and together with supporting evidence from medical history and neurologic examination, is very significant indicator toward confirming the diagnosis of MS
  • The MRI is also a very useful tool in clinical trials in assessing the value of new therapies by its ability to measure disease activity in the brain and spinal cord
Lumbar Puncture
  • In this test, cerebrospinal fluid (the fluid which flows around the brain and spinal cord) is tested for the presence of antibodies. Antibodies can occur with MS but they can also occur with other neurological conditions. The fluid is taken from the spinal cord by inserting a needle into the back and withdrawing a small amount of fluid. A local anaesthetic is given to numb the skin, and therefore whilst it is uncomfortable it is not usually painful. This test does require the person to lay flat for a number of hours after the test, and may require an overnight stay in hospital. Subsequently for some, a short period of recuperation may be required. This test may indicate MS but is not in itself conclusive

The diagnosis of MS is not always clear cut. The initial symptoms may be transitory and vague and confusing to both the person and their doctor. Invisible or subjective symptoms are often difficult to communicate to doctors and health professionals and sometimes people are at first dismissed as being neurotic or a hypochondriac.

Following an episode for which you have sought medical advice, your doctor may not have told you that MS is suspected. This delay may be very reasonable because the neurologist may wish to witness at least two distinct episodes with symptoms that are separated by at least a month and persisting for at least 24 hours.

A good relationship with your neurologist and family physician is essential. MS may have times of crisis and acute episodes which require specialist medical attention, but it is a disease that must be lived and managed every day. The time of diagnosis is stressful not only for the person with MS but for the family and carers who should also be fully informed as to the diagnosis, prognosis, treatment, management considerations and lifestyle adjustments associated with MS. The family physician and the local MS Society are important ongoing resources for care and information for those affected by MS.

The diagnosis of MS is a shock and often stereotypes of wheelchairs and disability tend to dominate one's thoughts. Nevertheless, it is most important to realise that many people with MS and their carers have recognised that it is still possible to live life to the full, taking into account any limitations caused by the illness. Thus, it is often unnecessary to give up work, education and social activities. Many people with MS can lead productive, fulfilling and relatively normal lives.


Which Drug?
--------------------------------------------------------------------------------
Currently there are a number of different drugs available for MS which are not directly related to symptom management and which may act to alter the course 
of the disease. (See also FAQ 'Is there any Treatment for MS' and MS MANAGEMENT Vol 3 No 2 Nov 1996 ) 
There are three beta interferons (Betaferon, Avonex, Rebif) and glatiramer acetate (Copaxone) and the features of each are different (eg method and frequency of injection). 

All these drugs have an impact on the frequency and severity of relapses, and the number of lesions as seen on MRI scans. Some of the drugs appear to have an effect of slowing the progression of disability. 

Decisions as to whether an individual is suitable for these medications, whether they should go on a drug and finally which one to choose, are matters for consultation between the person with MS and his/her medical advisors (neurologist, family physician). There are also particular considerations of availability, cost, health service attitudes etc which will also impact on the decision making process. 

This section will provide separate information about each of these drugs in the form of a series of frequently asked questions and answers. 

Betaferon 
Avonex (coming soon) 
Copaxone 
Rebif (coming soon)